Medical History Form

Name*

First Last

Email*

Address*

Street Address Address Line 2 City Province Postal Code

Birth Date*

General Information

Are you currently under the care of a physician?*

Yes
No

If yes, what for?

Are you currently under the care of a dermatologist?*

Yes
No

If yes, what for?

Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?*

Yes
No

Do you have any of the following medical conditions? (check all that apply)

Do you have any other health problems or medical conditions? Please list

Have you every had an allergic reaction to any of the following? (check all that apply)

Food
Aspirin
Hydroquinone
Latex
Hydrocortisone
Lidocaine
Other

Medications

What oral/topical medications are you presently taking?*

Birth control pills
Hormones
None

Are you on any mood altering or anti-depressant medication?*

Yes
No

Have you ever used Accutane?*

Yes
No

If yes, when did you last use it?

What herbal supplements do you use regularly?

History

Have you ever had laser hair removal?*

Yes
No

Have you had any recent tanning or sun exposure?*

Yes
No

Do you form thick or raised scars from cuts or burns?*

Yes
No

Do you have Hyperpigmentation (darkening of the skin), or Hypopigmentation (lightening of the skin or marks) after physical trauma?*

Yes
No

If yes, please explain

Have you ever had local anesthesia with licodaine?*

Yes
No

Which of the following best describes your skin type?

Always burn, never tan
Always burn, sometimes tan
Sometimes burn, always tan
Rarely burn, always tan
Brown, moderately pigmented skin
Heavily pigmented skin, very dark hair

Female Clients

Are you pregnant or trying to become pregnant?

Yes
No

Are you breastfeeding?

Yes
No

Are you using contraception?

Yes
No

Signature

Today's Date*

General Information

Medications

History

Female Clients

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